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Acuna, Victoria

Victoria Acuna
8809303

DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO FULL-TEXT DECISION

Note: This is the full text of the decision of the Discipline panel in
this matter. Any information identifying clients, witnesses or facilities
has been removed [ ]. The member’s name is omitted if the allegations
have been dismissed or if the results are not placed on the public portion
of the Register.

B E T W E E N:

REASONS FOR DECISION

This matter came on for hearing before a panel of the Discipline Committee of the College of Nurses of Ontario on October 16, 2002 and on December 20, 2002. The hearing was held at the College of Nurses of Ontario at Toronto.

The allegations against Victoria Acuna as stated in the Notice of Hearing (Exhibit #1) dated August 27, 2002 are as follows:

You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(1) of Ontario Regulation 799/93, in that, on or about September 1, 2000, while employed as a Registered Nurse at [the Hospital], you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession with respect to your care for [the client], and/or your documentation relating to that care; and/or

You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(1) of Ontario Regulation 799/93, in that, during the period from on or about September 21, 2000 to on or about October 12, 2000, while employed as a Registered Nurse at [the Hospital], you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession with respect to your care of various patients during supervised practice sessions, and/or your documentation of that care; and/or

You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(13) of Ontario Regulation 799/93, in that, on or about September 1, 2000, while employed as a Registered Nurse at [the Hospital], you failed to keep records as required with respect to your care of [the client]; and/or

You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(13) of Ontario Regulation 799/93, in that, during the period from on or about September 21, 2000 to on or about October 12, 2000, while employed as a Registered Nurse at [the Hospital], you failed to keep records as required with respect to your care for various patients during supervised practice sessions; and/or

You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that, on or about September 1, 2000, while employed as a Registered Nurse at [the Hospital], you engaged in conduct or performed an act, relevant to the practice of nursing, that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional with respect to your care for [the client], and/or your documentation relating to that care; and/or

You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that, during the period from on or about September 21, 2000 to on or about October 12, 2000, while employed as a Registered Nurse at [the Hospital], you engaged in conduct or performed an act, relevant to the practice of nursing, that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional with respect to your care for various patients during supervised practice sessions, and/or your documentation of that care; and/or

While employed as a Registered Nurse at [the Hospital], you displayed a lack of knowledge, skill or judgement, or a disregard for the welfare of a patient or patients of a nature or to an extent that demonstrates that you are unfit to continue to practise, or that your practice should be restricted, as provided by section 52(1) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, with respect to your care of [the client], and/or your documentation of that care, on or about September 1, 2000 and/or your care of various patients during supervised practice sessions, and/or your documentation of that care, during the period from on or about September 21, 2000 to on or about October 12, 2000.

The College sought leave of the Discipline panel to withdraw allegations #4 to #7 of the Notice of Hearing.

Counsel for the College advised the panel that the College was not calling any evidence with respect to the allegations set out in paragraphs 4, 5, 6, and 7 of the Notice of Hearing.

Member’s Plea

Victoria Acuna (the "Member") admitted the allegations set out in paragraphs numbered 1, 2, and 3 of the Notice of Hearing. The panel conducted a plea inquiry and was satisfied that the Member’s admission was voluntary, informed and unequivocal.

Agreed Statement of Facts

Counsel for the College advised the panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts (Exhibit #2) which provided as follows:

BACKGROUND

Victoria Acuna, RN, # 88-0930-3 ("the Member") has been registered as a Registered Nurse with the College of Nurses since 1987.

The Member received a certificate in nursing from the [ ] in 1973. She practised as a nurse in [ ] in 1973 – 1974. The Member immigrated to Canada where she worked as an RN in [ ] in 1974 – 1975. The Member then moved to Ontario where she worked as a graduate nurse in a retirement home from 1978 to 1987.

In 1987, the Member completed the Nursing Refresher Program at [ ] College, and first registered as a Registered Nurse with the College of Nurses of Ontario in 1987.

The Member was employed as an RN at [the Hospital] from 1987 to 2000. From 1987 to 1992, she worked in the Chronic Care Unit at the Hospital. She then worked in the Palliative Care Unit from 1992 to 1998. The Chronic Care and Palliative Care Units at the Hospital were combined in 1998. The Member was employed as an RN in the Palliative/Chronic Complex Care Unit at the Hospital from November, 1998 to September, 2000, at which time her employment ended in connection with the events described below.

The Member has been employed as an RN in the [ ] Unit of [ ] Hospital and in the [ ] Unit at [ ] Hospital in Toronto during the period from September, 2000 to the present.

The Member was very well liked by both staff and clients of the Palliative/Chronic Complex Care Unit of the Hospital.

MEMBER’S CARE AND TREATMENT OF [THE CLIENT]

On September 1, 2000, the Member was working 0700h-1500h in the palliative care unit of the Hospital. The Member was assigned to the care of 10 clients, including [the client]. [The client] was a 65-year old woman with a history of congestive heart failure, insulin-dependent diabetes, chronic obstructive pulmonary disease, liver disease and kidney disease. [The client] wished to be resuscitated if required, and wished to receive further necessary interventions in acute care to preserve her life. [The client] was receiving oxygen through nasal prongs, and was being monitored for her blood oxygen saturation.

The last entry in [the client’s] progress notes for the prior shift was for 2200h the previous evening, and indicated that at 1800h her blood sugar was 4.2 mmol/L. The normal range for blood sugar is 3.9-6.38 mmol/L, and the Hospital considers that an acceptable blood sugar range for diabetics is 6 -11 mmol/L. The progress note also indicates that at 1800h, [the client] had a good supper, that her oxygen saturation was 92%, and that her vital signs were as follows: 36.4 (temperature), 80 (pulse), 18 (respiration) and 120/60 (blood pressure).

As noted above, the Member began her shift at 0700h. She did not receive report from the nurse she relieved. The Member and her RN partner, [ ], were responsible together for approximately 20 patients in two adjoining modules.

The Member found [the client] apparently sleeping at 0730h. She measured [the client’s] blood sugar level, per physician orders, and found it to be 19 mmol/L. The Member administered [the client’s] regular scheduled dose of 15 units of Humulin 30/70 by subcutaneous injection. Humulin 30/70 is an intermediate-acting form of insulin that is active for up to 24 hours. The Member measured [the client’s] vital signs and found them to be 37.6 (temperature in Centigrade), 104 (pulse), 22 (respirations) and 149/80 (blood pressure). She did not note or record [the client’s] oxygen saturation level for that time.

A pulse rate in excess of 100 and a respiration rate in excess of 20 are considered problematic. Such symptoms should attract intervention on the part of nursing staff.

After completing her medication rounds, the Member returned to [the client] and also administered 8 units of Humulin R by subcutaneous injection, according to the sliding scale ordered by [the client’s] physician. Humulin R is a rapid-acting form of insulin, which acts over 6 hours, reaching peak effectiveness in 2-4 hours.

The Member held all [the client’s] regular oral morning medications because [the client] appeared to be still sleeping. These medications included Lasix, a diuretic that helps prevent the accumulation of fluid in the lungs of patients with congestive heart failure, and MS Contin, a form of morphine, for pain control. The Member indicated that she held the morning medications by placing an "H" in the appropriate space on the Medication Administration Record; however, she did not note that the medications were held, and the reason for doing so, in the progress notes for [the client].

At about 1030h, when the Member was returning from break, [ ], her RN partner, told the Member to check on [the client] because she appeared to be hyperventilating. If she testified, the Member would say that she does not recall any such comment from [her RN partner]. While relieving each other for breaks, each RN was responsible for all of the approximately 20 patients assigned to them.

Abnormally deep, rapid respiration and elevated pulse rate are consistent with diabetic ketoacidosis, an acute complication of diabetes that can occur when the blood sugar level is elevated.

The Member checked on [the client] and found that her oxygen prongs had come off. The Member checked [the client’s] vital signs at 1030h and found them to be as follows: 37.4 (temperature), 94 (pulse), 20 (respirations), 80% (oxygen saturation). She repositioned the oxygen prongs so that oxygen would be supplied as required and the prongs could not readily be dislodged by the patient.

In order to check for potential coma, the Member checked [the client’s] pupils and later explained that she found the pupils of equal size, neither constricted nor dilated, and equally reactive to light. She did not document these findings.

Establishing the size and reactivity of pupils is not an effective method for assessing a coma state. Coma state can be determined by the client’s eye-opening response, best motor response and best verbal response to different stimuli.

At 1100h, the Member checked [the client’s] oxygen saturation and found that it had increased to 90%. The Member charted the oxygen saturation level in the progress notes.

Shortly thereafter, the Member and [ ], Personal Support Worker, bathed [the client]. She was difficult to rouse, but opened her eyes when her name was called. She was also able to raise her arms to the headboard. The Member arranged [the client’s] oxygen prongs so that they would be less likely to come off again.

The Member was on break from 1215h to 1300h. Between 1215h and 1230h, [ ], Administrative Clerk, observed [the client] in her room. During lunch, she advised [ ], Case Manager, that [the client] did not look well or like her usual self, and suggested that [the Case Manager] might want to look at her.

When [the Case Manager] returned from lunch shortly after 1300h, she checked on [the client] and found her sweating profusely. [The Case Manager] was unable to get any response from [the client] by calling her name or from painful stimuli. [The client’s] lunch tray had been left on the over-the-bed table and had not been touched. She located [ ], Personal Support Worker, and asked her if the client had been responsive earlier that day. [The Personal Support Worker] indicated that she was difficult to rouse, but had opened her eyes when her name was called. [The Case Manager] then spoke to the Member on her lunch who told her that [the client] opened her eyes when her name was called, that all her vital signs were okay, that her blood sugar was 19 mmol/L in the morning, so the Member had administered Humulin R, that she had not eaten breakfast and that the Member had not checked her blood sugar a second time.

[The Case Manager] checked [the client’s] blood sugar and found it to be 1.7 mmol/L. [The Case Manager] and the Member began administering sugar and orange juice to [the client] sublingually. [The client] was unresponsive to all stimuli, and had no swallowing reflex.

Profuse sweating, elevated pulse, and alterations in level of consciousness, including coma, are characteristics of diabetic hypoglycemia, or low blood sugar, the causes of which can include the delay of a meal and excessive insulin.

In response to a question from [ ], a Physical Therapist who was in the room for a therapy appointment with [the client], the Member indicated that she thought [the client] had been sleepy in the morning as a result of the medication she was taking, and therefore she had not retested her blood sugar.

As requested to by [the Case Manager], the Member telephoned the on-call physician [ ]. The Member discussed [the client’s] condition with him, advising him that [the client’s] blood sugar had been elevated in the morning, but that now it was low, that she had given [the client] 8 units of Humulin R that morning, that her vital signs were stable, that her oxygen saturation was 90%, and that they were giving [the client] lots of sugar. He advised the Member to continue giving [the client] lots of sugar, and that he would see [the client] when he came to the unit.

[The Case Manager], the Member and [the Physical Therapist] continued to attempt to rouse [the client]. [The Case Manager] asked the Member to obtain some honey because she believed it would be safer and more effective than sugar, and the Member brought some. [The Case Manager] continued to take [the client’s] blood sugar every 10 minutes. Initial blood sugar readings remained low at 1.5 and 1.8 mmol/L. Blood pressure was 100/80. [The Physical Therapist], [The Case Manager] and the Member discussed using glucose injection to deliver the glucose directly, and the Member left the room stating that she would check for injectable glucose. She returned to the room twenty minutes later, indicating that she had to do her charting and check her other patients.

At 1350h [the client’s] blood sugar was approximately 2.7. Because of the difficulty in increasing and stabilizing [the client’s] blood sugar, she believed [the client] required IV glucose, and directed the Member to page [the on-call physician] again.

When [the on-call physician] arrived at approximately 1435h, he ordered stat IV glucose and for 911 to be called to take the client to Emergency Department at [another hospital]. The Member called the hospital IV team, and while on the phone with a member of the team, asked [the on-call physician] if the situation was an emergency. [The Case Manager] understood the comment to indicate that the Member still did not recognize the gravity of the situation. If she testified, the Member would state that her question was directed to a choice of emergency services ("911" or "Emergency Ambulance Service") for which different telephone numbers were posted at the telephone.

After [the client] was started on IV glucose, paramedics arrived and she was intubated and taken to [the other hospital]. She was seen in Emergency and later admitted to the Intensive Care Unit.

SUPERVISED PRACTICE SESSIONS

As a result of the incidents with [the client], representatives of [the Hospital] management met with the Member on September 12, 2000 and discussed the Member’s care of [the client] with her. Subsequently, management representatives decided to suspend the Member with pay, effective that day, and establish a learning contract with her for a period September 18 to 29, 2000, during which time the Member would continue to receive her salary. The objectives of the Learning Contract were that the Member be able to do the following:

Perform prompt and accurate assessments of clients

Promptly chart observational assessments of clients

Report seriousness of client observations to the MD

Set priorities for the most ill clients and delegate clients’ care to other staff

Be familiar with diabetes management

Practice respiratory assessment

Administer medication safely

Administer care in a timely manner.

Pursuant to the Learning Contract, the Member conducted supervised practice sessions with [ ], RN, Nurse Educator, on September 21, 22, October 3, 4, 5, 11, 12 and 13 with a 50% client load of between 4-6 clients.

At the completion of the supervised practice sessions, [the Nurse Educator] prepared a summary of the Member’s progress from her observations on October 11, 12 and 13. With respect to each of the learning objectives, [the Nurse Educator’s] comments included the following shown below in italics.

Perform prompt and accurate assessments of clients Further attention is required in this area in order for Vicki to perform independently. Vicki needs to allocate more of her time to gathering data from the care plan and the chart at the beginning of the shift to be completely informed of her patients’ status....

Promptly chart observational assessments of clients Continued observation of Vicki’s documentation would be beneficial to ensure that all relevant data is reported upon. This is one area that Vicki has shown great improvement since the onset of the learning contract.

Report seriousness of client observations to the MD Vicki demonstrated clear and professional communication skills in this area and was able to make the contact with the physician have a productive outcome. Vicki should work towards this level of communication in all instances.

Set priorities for the most ill clients and delegate clients’ care to other staff .... Vicki has been inconsistent with her ability to prioritize....This is an area that requires considerable growth for several reasons . . . What is absent . . . is the clear communication with the other staff to determine the status of the clients she is responsible for if it indeed they require her attention. When Vicki assigns the personal care, she did little or no assessment of that patient for the duration of the shift. Despite verbalizing to Vicki the difference between delegating and assigning she lacks the understanding that the ultimate responsibility of the patient remains with her as a Registered Nurse.

Be familiar with diabetes management Vicki was responsible for one diabetic client over a three-day period. She was able to demonstrate and apply knowledge necessary to competently care for this client.Vicki required prompting to complete the quality assurance test on the glucose monitor, as it had not been done the previous night. Vicki should continue to review this skill to ensure it is performed accurately and consistently because the quality assurance test is an essential part of ensuring a quality blood test.

Practice respiratory assessment Vicki has been able to demonstrate an increasing ability to apply knowledge related to respiratory assessment in a clinical setting. This remains an area of growth to ensure that there is consistent performance in terms of technique, use of proper terminology as well as recognition and interpretation of ascultated chest sounds.

Administer medication safely ... She continues to have some difficulty though as there were several drugs that Vicki was unfamiliar with and required prompting to investigate them in a drug handbook. Vicki also is having trouble with landmarking of intramuscular injection sites....

Example: ... Unsure of landmarking for an intramuscular injection into the deltoid....; Was able to calculate dosages on two occasions with pen and paper but on a third occasion was unable with pen and paper to calculate a dose of morphine as written below:

Ordered doses = 2.5 mg Dose on Hand – 10mg/ml

Vicki was able to verbally tell me she would give .25mls but could not show me on paper how she arrived at this volume. She also attempted to use a syringe that was not calibrated to deliver this calculated dose.

With the knowledge gaps in this area, it would be recommended that Vicki not administer medications independently at this time.

Administer care in a timely manner Vicki has been able to improve her time management skills and has been able to administer medications, perform charting, provide personal care needs and have her breaks.

Vicki should continue to work towards developing this skill and move towards a more realistic assignment of 8-10 clients.... There is still considerable time lost in returning to the care plans for data that should have been collected at the beginning of the shift e.g., patients’ ambulatory status. ... There is little evidence of on-going communication with fellow Registered Nurses or the unregulated staff throughout the shift....

[The Nurse Educator’s] conclusion was that the Member was unable to meet the objectives of the Learning Contract at that time.

In response to this information, [the Hospital] determined that the Member should not practice without supervision. It proposed to the Member that she complete the RN Refresher Program at [ ] College or the one-day Nurse Educational Assessment Program at [ ] University at the Hospital’s expense, and with full pay and benefits, and her position held for her. She declined both proposals and grieved her suspension, on the advice of her Union. Ultimately, the Member resigned from the Hospital.

If she testified, the Member would state that her performance under the Learning Contract may have been affected by the advice she received in early September, 2000 that her husband had been diagnosed with cancer and that his prognosis was not good. The Member’s husband died in July, 2001.

ADMISSIONS

The Member admits that, as is set out in Allegation 1 of the Notice of Hearing, on September 1, 2000, she contravened a standard of practice of the profession with respect to her care for [the client] by:

failing to adequately monitor [the client’s] blood sugar level after it had been 19 mmol/L, and after she had administered two forms of Humulin, at 0730h;

holding [the client’s] morning medications, including Lasix and MS Contin, for the reason that she believed [the client] was sleeping;

failing to recognise and respond to the clinical manifestations of hyper- and hypoglycemia in [the client];

failing to be aware of an effective method of assessing [the client’s] level of consciousness (i.e. coma);

failing to recognise the potentially harmful consequences to [the client], a diabetic, of missing, or being late for a meal;

leaving the care of [the client] to [the Case Manager] to complete her charting or to check other patients while [the client’s] status was critical and unstable;

The Member admits that, as is set out in Allegation #2 of the Notice of Hearing, from September 21, 2000 to October 12, 2000, she failed to meet the standards of the profession with respect to her care of various clients during supervised practice sessions by failing to meet the objectives of the Learning Contract with [the hospital], in that the objectives constituted knowledge and skills that are essential to the practice of all RNs in Ontario.

The Member admits that, as is set out in Allegation #3 of the Notice of Hearing, on September 1, 2000, she failed to keep records as required with respect to her care of [the client] by failing to note that she had held [the client’s] morning medications, and the reason for doing so in the Multidisciplinary Progress Notes for [the client].

Decision

The panel considered the Agreed Statement of Facts ("ASF") and finds that the facts support a finding of professional misconduct and, in particular, finds that the Member committed acts of professional misconduct as alleged in paragraphs 1, 2, and 3 of the Notice of Hearing in that the Member :

contravened the standard of practice of the profession or failed to meet the standards of practice of the profession with respect to her care of [the client], as set out in paragraph 37 of the Agreed Statement of Facts.

contravened a standard of practice of the profession or failed to meet the standards of practice of the profession with respect to her care of various patients during supervised practice sessions, as set out in paragraph 38 of the Agreed Statement of Facts.

failed to keep records as required with respect to her care of [the client] as set out in paragraph 39 of the Agreed Statement of Facts.

The panel makes no finding with respect to paragraphs 4, 5, 6 and 7 of the Notice of Hearing. The panel grants leave to the College to withdraw paragraphs 4, 5, 6 and 7 of the Notice of Hearing.

Penalty

Counsel for the College advised that a Joint Submission on Penalty (Exhibit #3) had been agreed upon.

Joint Submission on Penalty

Victoria Acuna, RN, #88-0930-3 ("the Member") and the College of Nurses of Ontario ("the College") respectfully submit that, in view of the circumstances set out in the Agreed Statement of Facts, and the Member’s admissions of professional misconduct therein, the panel of the Discipline Committee should make an order as follows:

Requiring the Member to appear before the panel to be reprimanded.

Directing the Executive Director to suspend the Member’s certificate of registration for a period of thirty days, commencing on October 28, 2002 or on such later date as the Executive Director may specify to accommodate [scheduling concerns].

Directing the Executive Director to impose the following terms, conditions and limitations on the Member's certificate of registration:

The Member will provide to the Director of the Investigation and Hearings Department of the College ("the Director") proof that she has successfully completed one of the following groups of courses by December, 2003:

The following [ ] college courses:

[ ] Health Assessment,

[ ] Adult Nursing,

[ ] Pharmacology and Medication Administration,

[ ] Nursing Skills, unless she is granted an exemption from this course by [the college] on the basis that her nursing skills are sufficient to satisfy the course evaluation standards, and Nursing Practice; or

The following [ ] college courses:

[ ] Health Assessment,

[ ] Acute and Chronic Illness Theory,

[ ] Acute and Chronic Illness Clinical,

[ ] Technology Update and Skills Review, and

[ ] Acute and Chronic Illness Consolidation; or

Such other group of courses as is approved by the Director in advance.

The Member will only practice in a health care facility where other registered nurses are employed, and will not practice independently, or in the community. The Member will notify the Director in writing of all such facilities within fourteen days of commencing such practice, with the notice in writing to be provided by such verifiable means as a courier or registered mail;

The Member will only practice in a health care facility or facilities where the health care facility or facilities have agreed in advance to supervise the Member’s practice according to a written supervision plan that is in accordance with the terms set out in paragraph 3.e) below. Before agreeing to a supervision plan, the health care facility or facilities must have received a copy of the panel’s Penalty Order in this matter, including the Notice of Hearing, Agreed Statement of Facts, and Joint Submission on Penalty;

The Member will not practice at a facility or facilities on behalf of a nursing agency unless the facility where she practices complies with the condition set out in paragraph 3.c), above;

The supervision plan for any health care facility will contain the following terms:

The Member may only practice in respect of patients requiring palliative, long-term care, or alternative level of care, or of patients requiring other types of care where the Director has consented in advance.

The health care facility agrees to have the Member’s practice supervised on every shift by a person who is registered as a Registered Nurse with the College, and who has received a copy of the panel’s Penalty Order, including the Notice of Hearing, Agreed Statement of Facts, and Joint Submission on Penalty, until the Member has completed 24 months of practice following the period of suspension referred to in paragraph 2. above.

The Member shall not supervise other nursing staff, or student nurses, with respect to nursing care. It is understood that the Member’s duties may involve some direction of nursing staff, or student nurses, which does not involve supervision with respect to nursing care. The health care facility may review any questions regarding this limitation on the Member’s practice with the Director and the Director, if necessary, shall respond to the inquiry in writing, with a copy of the response to the Member.

The health care facility agrees to advise the Director immediately if the supervising staff comes to believe that the Member is unable to practice under the terms set out in the supervision plan, and/or in a manner that is consistent with the standards of practice of the profession.

The health care facility agrees to notify the Director in writing that it has agreed to implement the supervision plan described in paragraphs 3.c) – e) above and that copies of the panel’s Penalty Order, including the Notice of Hearing, the Agreed Statement of Facts and the Joint Submission on Penalty, have been provided to all staff who will be supervising the Member.

The limitations on the Member’s practice and the terms of the supervision plan in paragraphs 3. b), 3.c), 3.d), and 3.e) will remain in effect until the Member has demonstrated to the Director that she has completed 24 months of practice following the period of suspension referred to in paragraph 2. above (for the purposes of clarity, more than 24 calendar months may be required to complete 24 months of practice if, for example, there are breaks in the Member’s employment).

Directing the Executive Director to suspend the Member’s certificate of registration effective January 1, 2004 unless by that date the Member has provided proof to the Director that she has successfully completed all of the courses in one of the groups of courses in accordance with paragraph 3.a) above, with the suspension to remain in effect until the Member has provided such proof to the Director.

Submissions by both legal counsel were made. The panel reviewed the Joint Submission on Penalty and while in general agreement with the terms outlined, had difficulty accepting one component of the penalty. Further submissions were made. The panel was unable to contact Independent Legal Counsel (ILC) for advice, as it was late in the day. The hearing was adjourned pending advice from ILC to the panel. The panel proposed that the next date for reconvening the hearing would be November 11, 2002.

The panel contacted ILC by telephone and advice was given regarding changes to the Joint Submission on Penalty. The advice by ILC was forwarded to both College counsel and counsel for the Member in writing. Further submissions were made by both counsel in writing and forwarded to the panel. Correspondence dated November 7, 2002 from counsel for the Member requesting a further adjournment, as issues had arisen with the Members employer regarding their responsibilities in the decision, was sent to the panel. The panel contacted ILC by telephone for advice. A letter was sent from the panel chairperson to both legal counsel granting a further extension to the adjournment.

The hearing reconvened on December 20, 2002. Catherine Charlton, Public Member was not present. A new Joint Submission on Penalty (Exhibit #4) was presented to the panel. The new Joint Submission on Penalty provides as follows:

New Joint Submission on Penalty

Victoria Acuna, RN, #88-0930-3 ("the Member") and the College of Nurses of Ontario ("the College") respectfully submit that, in view of the circumstances set out in the Agreed Statement of Facts, and the Member’s admissions of professional misconduct therein, the panel of the Discipline Committee should make an order as follows:

Requiring the Member to appear before the panel to be reprimanded.

Directing the Executive Director to suspend the Member’s certificate of registration for a period of thirty days, with the suspension to commence on December 20, 2002 and continue until January 18, 2003.

Directing the Executive Director to impose the following terms, conditions and limitations on the Member's certificate of registration:

REMEDIAL COURSEWORK

The Member will provide to the Director of the Investigation and Hearings Department of the College ("the Director") proof that she has successfully completed one of the following groups of courses by December, 2003:

The following [ ] college courses:

[ ] Health Assessment,

[ ] Adult Nursing,

[ ] Pharmacology and Medication Administration,

[ ] Nursing Skills, unless she is granted an exemption from this course by [the college] on the basis that her nursing skills are sufficient to satisfy the course evaluation standards, and

[ ] Nursing Practice; or

The following [ ] college courses:

[ ] Health Assessment,

[ ] Acute and Chronic Illness Theory,

[ ] Acute and Chronic Illness Clinical,

[ ] Technology Update and Skills Review, and

[ ] Acute and Chronic Illness Consolidation; or

Such other group of courses as is approved by the Director in advance.

TERMS OF SUPERVISION

General

From the time the Member resumes, or commences, practice with any health care facility after she completes the period of suspension set out in paragraph 2 above, the Member’s practice will be subject to a period of supervision for at least 24 months of practice, any extensions of which will occur as a result of provisions set out below. During the supervision period, the Member

will only practice in a health care facility where the health care facility has agreed in advance to supervise the Member’s practice according to the terms set out in this section (GENERAL) and in the sections entitled INITIAL SIX MONTHS OF PRACTICE and SUBSESQUENT 18 MONTHS OF PRACTICE, below, as appropriate. Before agreeing to supervise the Member, the health care facility must have received a copy of the panel’s Penalty Order in this matter, including the Notice of Hearing, Agreed Statement of Facts, and Joint Submission on Penalty;

will not practice at a health care facility on behalf of a nursing agency unless the facility where she practices complies with the condition set out in paragraph 3.b)i., above, and the Director has approved of such arrangements in advance;

may only practice in respect of patients requiring palliative, long-term care, or alternative level of care, or of patients requiring other types of care where the Director has consented in advance;

will only practice in a health care facility where other registered nurses are employed, and will not practice independently, or in the community. The Member will notify the Director in writing of all such facilities within fourteen days of commencing such practice, with the notice in writing to be provided by such verifiable means as a courier or registered mail.

During the period of supervision, the following terms apply:

Initial 6 Months of Practice – Intensive Supervision

From the time the Member resumes, or commences, practice with any health care facility after she completes the period of suspension, and for the subsequent six months in which she is engaged in practice, the Member will only practice at a health care facility where

the health care facility agrees to have the Member’s practice supervised on every shift by a person who is registered as a Registered Nurse with the College, and who has received a copy of the panel’s Penalty Order, including the Notice of Hearing, Agreed Statement of Facts, and Joint Submission on Penalty, or, if available, a copy of the panel’s decision and reasons;

the Member shall not supervise other nursing staff, or student nurses, with respect to nursing care. It is understood that the Member’s duties may involve some direction of nursing staff, or student nurses, which does not involve supervision with respect to nursing care. The health care facility may review any questions regarding this limitation on the Member’s practice with the Director and the Director, if necessary, shall respond to the inquiry in writing, with a copy of the response to the Member;

the health care facility agrees to notify the Director in writing within 14 days of the commencement of the period of intensive supervision that it has agreed to supervise the Member’s practice according to the terms set out in this section (INITIAL 6 MONTHS OF PRACTICE) and in the section entitled GENERAL, above, and that copies of the panel’s Penalty Order, including the Notice of Hearing, the Agreed Statement of Facts and the Joint Submission on Penalty, or, if available, a copy of the panel’s decision and reasons, have been provided to all staff who will be supervising the Member;

the health care facility agrees to advise the Director immediately if the supervising staff comes to believe that the Member is unable to practice under the terms set out in this section (INITIAL 6 MONTHS OF PRACTICE) and in the section entitled GENERAL, above, and/or in a manner that is consistent with the standards of practice of the profession.

Subsequent 18 Months of Practice – Practice Appraisals

After the Member has completed the six-month period of intensive supervision at a single health care facility, and for the following 18 months of practice, the Member may only practice at a health care facility where

the health care facility at which the Member practices agrees to perform appraisals of her practice at intervals of six months of practice for 18 months of practice, or until her employment at the facility ends;

the health care facility agrees to notify the Director in writing within 14 days of the commencement of the 18-month period in which she is subject to performance appraisals that it has agreed to agreed to perform appraisals of the Member’s practice consistent with the terms set out in this section (SUBSEQUENT 18 MONTHS OF PRACTICE) and the section entitled GENERAL, above and that copies of the panel’s Penalty Order, including the Notice of Hearing, the Agreed Statement of Facts and the Joint Submission on Penalty, or, if available, the panel’s decision and reasons, have been provided to all staff who will be performing the appraisals of the Member’s practice;

the health care facility agrees to advise the Director immediately if the supervising staff comes to believe that the Member is unable to practice under the terms set out in this section (SUBSEQUENT 18 MONTHS OF PRACTICE) and the section entitled GENERAL, above, and/or in a manner that is not consistent with the standards of practice of the profession.

Change of Employment

If the Member’s employment at the facility ends for any reason while her practice is being supervised for 6 months of practice, all of the terms set out in the sections entitled GENERAL and INITIAL 6 MONTHS OF PRACTICE, above, apply with respect to her practice at any subsequent facility that agrees to employ her until she has practiced with supervision for six months of practice at a single facility, after which time the terms set out the terms set out in the sections entitled GENERAL and SUBSEQUENT 18 MONTHS OF PRACTICE, above, apply to her practice.

If the Member’s employment at the facility ends for reasons that are related to deficits in her nursing skills, knowledge or judgement after completing six months of supervised practice at a facility, all of the terms set out in the sections entitled GENERAL and INITIAL 6 MONTHS OF PRACTICE, above, apply with respect to her practice at any subsequent facility that agrees to employ her until she has practiced with supervision for six months of practice at a single facility, after which time the terms set out the terms set out in the sections entitled GENERAL and SUBSEQUENT 18 MONTHS OF PRACTICE, above, apply to her practice.

If the Member’s employment at the facility ends for reasons that are not related to deficits in her nursing skills, knowledge or judgement after completing six months of supervised practice at a facility, the Member is not required to have her practice supervised for a 6-month period of practice at any subsequent facility that employs her, but may complete the 18-month period of practice, in accordance with the terms set out in the sections entitled GENERAL and SUBSEQUENT 18 MONTHS OF PRACTICE, above, or any part of the period, for another employer or employers.

Directing the Executive Director to suspend the Member’s certificate of registration effective January 1, 2004 unless by that date the Member has provided proof to the Director that she has successfully completed all of the courses in one of the groups of courses in accordance with paragraph 3.a) above, with the suspension to remain in effect until the Member has provided such proof to the Director.

Reasons for Decision

Counsel for the College advised that both the College and the Member had agreed upon this Joint Submission on Penalty.

Counsel for the College submitted that the penalty addressed the panel’s original concerns with the first Joint Submission on Penalty. The panel’s concerns involved the Member practising at a facility or facilities on behalf of a nursing agency. The panel was not confident that the monitoring protocol would be met under these circumstances. The Joint Submission on Penalty (Exhibit #4) meets the needs of the public, the employer, and the Member. It provides specific deterrence and a rehabilitative component to the Member. It provides for a general deterrence to the entire membership.

Counsel for the Member agreed with College counsel’s submissions and went on to state that this Joint Submission on Penalty was in part due to the participation and foresight of the professional administrative staff of the Member’s employer. He stated that the penalty was practical and reasonable.

Penalty Decision

The panel unanimously accepted the Joint Submission on Penalty (Exhibit #4) and accordingly makes an order in accordance with the terms of the Joint Submission on Penalty (Exhibit #4). The penalty includes a reprimand, 30 day suspension, remedial course work and terms of supervision.

The panel determined that the proposed penalty involved the College, the Member and the employer in the terms, conditions and limitations put on the Member’s certificate of registration. The panel concluded that this collaboration between the three parties was instrumental in reaching an agreement. The penalty addresses the need for a general deterrence to the entire membership, as well as a specific deterrence to the Member. The completion of the required upgrading courses and the monitoring and supervision in the workplace provides assurances that the standards of practice will be met by the Member. Safeguards are in place to address the supervision of the Member in the event of termination from her current place of employment. The panel concluded that the penalty is reasonable and in the public interest.

I, Cheryl Beemer, R.N., sign this decision and reasons for the decision, as Chairperson of this Discipline panel and on behalf of the members of the Discipline panel as listed below: